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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500823
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:18:14 PM

Document Has Been Signed on 08/29/2024 03:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HIGHLAND MANOR GUEST HOMEFACILITY NUMBER:
191500823
ADMINISTRATOR/
DIRECTOR:		AARON KHODORKOVSKYFACILITY TYPE:
735
ADDRESS:3570 E. IMPERIAL HWY.TELEPHONE:
(310) 631-7569
CITY:LYNWOODSTATE: CAZIP CODE:
90262
CAPACITY: 106CENSUS: 106DATE:
08/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Administrator Aaron KhodorkovskyTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 08/29/2024 at 1:45 pm Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Hollie Enriquez conducted an unannounced Case Management - Other visit and was met by Administrator Aaron Khodorkovsky the purpose of the visit was explained. Administrator toured LPM and LPA through the interior of the facility , which included the TV room, Kitchen and Medication Room. LPM reviewed and obtained copies of client C1's client records; which includes admission records and hospice records. LPM and LPA interviewed four (4) staff.

No citations were issued at the time of this visit.

An exit interview and copy of this report has been provided to the Administrator Khodorkovsky.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Hollie Enriquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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